34

Asia Pac J Clin Nutr 2009;18 (1): 34-40

Original Article

Iodine status and thyroid function of pregnant, lactating women and infants (0-1 yr) residing in areas with an effective Universal Salt Iodization program
Yanling Wang PhD1,2, Zhongliang Zhang MS3, Pengfei Ge MS2, Yibo Wang SD1, Shigong Wang MS4
1 2

College of Earth and Environment Sciences, Lanzhou University, Lanzhou Gansu, China Gansu center for diseases control and prevention, Lanzhou Gansu, China 3 The first people hospital of Lanzhou city, Lanzhou Gansu, China 4 College of Atmospheric Sciences, Lanzhou University, Lanzhou Gansu, China
Objective: To assess the iodine nutrition and thyroid function of pregnant women, lactating women and infants residing in areas where the Universal Salt Iodization program is in place. Methods: Pregnant women, lactating women and infants were selected randomly in the regions where iodized salt coverage rate is more than 90% since 2000. Urine iodine levels of pregnant woman, lactating woman and infants, milk iodine of lactating woman, thyroid-stimulating hormone (TSH) and free T4 of women were tested respectively. Results: Median Urinary Iodine (MUI) of infants, three groups of pregnant women (first, second and third trimester) and two groups lactating women (breastfeeding less than or more than six months) were 233, 174, 180, 147, 126 and 145 μg/L, respectively. Median milk iodine of lactating women was 163 μg/L. Percentage of milk iodine < 150 μg/L of early lactating women was 40% less than that of late lactating women (p < 0.01).There was a positive correlation between urine iodine of infants and milk iodine of lactating women (r = 0.526, p = 0.000). T4 of two women were above or below the reference range. Total 15.4% women’s TSH were abnormal. Most of these women’s urinary iodine were lower than 150 μg/L. Conclusion: Iodine status of most of the target population for Universal Salt Iodization program is adequate, but iodine deficiency still existed in some. To assure every new life’s brain not be damaged by iodine deficiency, iodine status of targeted populations should be monitored and supplements provided according to the monitoring outcomes.

Key Words: iodine nutrition, iodized salt, thyroid hormone, urine iodine concentration, milk iodine concentration

INTRODUCTION Iodine deficiency (ID) has multiple adverse effects on growth and development in humans. Those are collectively termed the iodine deficiency disorders (IDD) and are one of the most important and common human diseases. 1, 2 Pregnant and lactating women and infants are most susceptible to iodine deficiency disorders. In the pregnant and lactating woman, iodine deficiency is related to disorders that affect mothers and fetuses: increased early and late miscarriage, intellectual disability, endemic cretinism, neonatal hypothyroidism, neonatal hyperthyroitropenemia, increased perinatal and infant mortality, and growth retardation. During the period of brain development, even mild iodine deficiency can cause damage. In order to protect the intelligence of those at risk, pregnant, lactating women and infants less than two years old are the targeted in iodine deficiency disorders (IDD) prevention and control. Iodine is one of the essential trace elements for infant’s growth and development. Currently the whole world is still facing a threat of iodine deficient disease. Iodine deficiency causes maternal hypothyroxinemia, which affects pregnant women even in apparently iodine-

sufficient areas, and often goes unnoticed because Lthyroxine (T4) levels remain within the normal range, and thyroid-stimulating hormone (TSH) is not increased. Even a mild hypothyroxinemia during pregnancy increases the risk of neurodevelopmental abnormalities, and experimental data clearly demonstrate that it damages the cortical cytoarchitecture of the fetal brain. 3 Iodine status of breastfed infants depends on the concentration of iodine in breast milk. The activities of sodium/iodine symporter and 5’- deiodinase in mammary glands increases the concentration and activity of iodine in breast milk. Hence, the iodine status of breastfed infants is better than that of formula fed infants. However, the iodine concentration in human milk varies widely due to environmental, pharmacological and maternal physical factors,
Corresponding Author: Dr. Yanling Wang, Gansu center for diseases control and prevention, Duanjiatan 371, Lanzhou Gansu 73020, PR China Tel: +86-931-4678766; fax; Fax: +86-931-4695985 Email: wylxiao@126.com Manuscript received 6 October 2008. Initial review completed 5 March 2009. Revision accepted 6 March 2009.

Y Wang. The urban sites of Yongjin County were divided into five geographic locations (east. first. were sequentially admitted into the study. at provincial level. breast milk and blood samples differed from the total number of subjects.7% and median urinary iodine level of 120 μg/L. The initial iodization level was set at 50 mg/kg (50 ppm). second and third trimester). P Ge. and urinary iodine concentrations of infants. 10.9 ≥ 300 (μg/L) 9. Yongjin County located in Gansu province is one of the iodine deficient regions in China.65-2.3 (1) 56. With the exception of pregnant women in the third trimester (147 μg/L). north and center). one community was identified and ten samples of each group were selected randomly (three groups of pregnant women. Non-parametric analyses (chisquare tests and median tests) were used for comparisons among groups.6 (7) 56. and at the same time lactating women provided samples of breast milk for iodine analyses.3 ng/dL and TSH was 0. Pregnant women Urinary iodine medians of pregnant women in the first. More than 90% of the drinking water has a iodine content of less than 10 μg/L in Gansu.0% (70) Figures in parentheses are the number of pregnant women. A total of 125 healthy pregnant women (first. adapted from the general Sandell-Kolthoff technique recommended by ICCIDD. Measurement Casual urine samples were collected from the above five groups of people and in bottles tightly sealed and refrigerated at 4°C until laboratory analysis. Iodine in urine was measured by the National standard method of China’s Ministry of Health 6. Fortification of salt with iodine has been recognized as the most effective and cost-efficient strategy to prevent iodine deficiency disorders. and their infants).9 21. 4.5 It is important to know if iodine status of pregnant women. south. the medians of urinary iodine of schoolchildren. Universal salt iodization was carried out in 1995 in China. Pearson test was used for correlation analysis of urinary iodine concentrations. T4 and TSH were measured by chemiluminescent immunoassay (CLIA). MATERIALS AND METHODS Subjects Yongjin County was selected as study site where iodized salt coverage rate is more than 90% since 2000. All women included in study were demanded residing in Yongjin city for more than five years. west.9% (23) All 125 169 5. for a given population (including lactating women). based on the catalytic effect 35 of iodine on the reaction between cerium IV and arsenic III. that the median urinary iodine concentrations (UICs) must be 100-199 μg/L in clinically healthy subjects and 150-249 μg/L in clinically healthy pregnant women. Z Zhang. Pregnant and lactating women provided samples of serum for free T4 and TSH analyses. 8 Breast milk iodine was measured by similar adaptations after appropriate digestion 9. Gansu province was classified in 1995 as having a severe level of IDD according to the WHO/UNICEF/ICCIDD criteria with a total goiter rate in school children of 38. the study was explained to the women and consents were obtained. median urinary iodine level was 192μg/L and qualified iodized salt consumption rate was 88.8 27. Urinary iodine values of pregnant women during each trimester of pregnancy Median uriTrimester Samples Samples with Total nary iodine of pregwith UIC samples concentration UIC ≥ 150 μg/L nancy < 50 μg/L (μg/L) First 30 174 3. Y Wang and S Wang and this change poses an important effect on infant’s growth and development. second and third trimester. Nonfasting bloods were obtained from five groups of women. RESULTS Urinary iodine concentration Infants The median urinary iodine (MUI) of infants was 233μg/L which reached the MUI criterion recommended by WHO/UNICEF/ICCIDD (1)(Table 1).0 61 233 (6) (17) (13) (25) N Figures in parentheses are the number of infants Table 2. Before the study. Serum was prepared by centrifugation within 2h of blood collection and frozen at -20°C until analysis of thyroid hormones.3 41. . breast milk or blood samples.4-4. These subjects were asked to provide casual samples of urine for iodine analyses.2 (4) 47.0). third trimesters were 174 μg/L.9 200-299. second. lactating women and infants can be determined and to know the status of women’s thyroid function at present iodine salt concentration.3 (2) 63.9%. the total goiter rate in school children was 13. The Reference range for T4 was 0. the number of urinary. In each location.7% (17) Second 47 180 4. Because only some women provided urinary.0 μIU/mlL Statistical methods Statistical analysis was performed using SPSS for Windows (Version 10. Urinary iodine values of infants Median urinary iodine Frequency distribution(%) concentration < 100 100-199. the urinary iodine medians of pregnant women in the first and second trimesters were in the 150-249 μg/L range defined as optimal by Table 1. breastfeeding less than and more than six months. 7 The WHO/ UNICEF/ICCIDD established. 180 μg/L and 147 μg/L respectively.8% (30) Third 48 147 8. After ten years of Universal Salt Iodization (USI). 100 healthy lactating women and their 61 healthy infants (0-1 yr) who had no previous history of thyroid disease or medications that affect thyroid status. were over 300 μg/L in 18 and 14 provinces in 1997 and 1999. milk iodine concentrations of lactating women. later reduced in 2000 to 35 ppm after national monitoring by urinary iodine concentration showed this intake to be excessive. respectively. and two groups lactating women. The study was approved by the local institutional ethics committee.5%. That of all pregnant women was 169 μg/L (Tables 2).

1213 The breast milk iodine medians was 240μg/L in the women lactating for less than 6 months and was 122 μg/L in the women lactating longer than 6 month.2% (24) 40.01 n Median(μg/L) iodine content in milk <100 μg/L < 150 μg/L 49 48 97 240 (47.90% Breast milk iodine less than urinary iodine concentration (%) 19. (r = 0. p < 0. Comparison of iodine concentrations in breast milk and urine of lactating women. Frequency distribution of urinary iodine of lactating women .48-391) 25. 80. which reached the MUI criterion (≥ 100 μg/L) recommended by WHO/UNICEF/ICCIDD. Breast milk iodine excretion significantly decreased in women lactating of longer than 6 months.90% 48. Iodine concentrations in human milk Table 4 shows iodine values in breast milk of lactating women.5%(17) 44.01). That showed that iodine concentrations in mammary glands during early lactation was greater than what was found when a women had been lactating for longer than 6 months (Table 5).9% of women breastfeeding more than six months had breast milk iodine concentrations higher than urinary iodine concentrations (p < 0. while 48.6 (7) 11. Of women breastfeeding less than six months.3% (43) The percentage of breast milk iodine < 150 μg/L of women lactating for less than 6 months was 40% less than that of women lactating for longer than 6 months (p < 0. Although iodine is concentrated by the mammary gland. 8 The frequency distribution of urinary iodine of lactating women is shown in Figure 1. Comparing iodine concentrations in breast milk and urine of lactating women.10% 51. Median iodine content in breast milk of lactating women (μg/L) Lactating women Breastfeeding Less than six months Breastfeeding more than six months All ** p<0.526. 17.01). There were no correlation relationships among urinary iodine concentrations of lactating women. 11.5 (6) 13.(1) Lactating women The median urinary iodine concentration in two groups of lactating women were 126 μg/L and 145 μg/L respectively (Table3). (%) 30 25 20 15 10 5 0 0- 50- 100- 150- 200- 300- Breastfeeding Less than six months Breastfeeding more than six months Fig 1.9% had higher breast milk iodine concentrations than urinary iodine concentrations. Urinary iodine values of lactating women Lactating women Breastfeeding Less than six months Breastfeeding more than six months All Samples Samples with Total Median with UIC < UIC ≥ 150 samples UIC (μg/L) 50 μg/L μg/L 48 52 100 126 145 136 14.5% of all lactating women had low iodine concentrations (< 100 μg/L) in their breast milk.0% (40) Table 5. Relationship among urinary iodine concentrations and breast milk iodine concentrations in lactating women and urinary iodine concentrations in infants We found a positive correlation between the urinary iodine concentrations in infants and the breast milk iodine concentrations of lactating women. Breastfeeding less than six 47 months Breastfeeding more than six 47 months Table 4.iodine contion (μg/L) centration (μg/L) (%) 240 122 126 145 80.0 (13) 33.48-875) 17. Median Breast milk Breast urinary iodine more milk iodine than urinary Iodine N median concentra. breast milk WHO/UNICEF/ICCIDD.36 Iodine status and thyroid function of target people Table 3.01).0%(12) 64.6%**(31) 163 (16.3% (16) 46.5%**(12) 122(16.2%(5) 24.33-875) 10. The breast milk iodine median of 163 μg/L in all lactating women was within the optimal range of 100-200 μg/L.10% Lactating women Figures in parentheses are the numbers of lactating women.

Thyroid-stimulating hormone and free T4 in pregnant and lactating women Women Pregnant (first Trimester) Pregnant (second Trimester) Pregnant (third Trimester) Lactating women (< 6 months) Lactating women (> 6 months) All Total samples 30 47 50 49 52 228 TSH median (μIU/mL) 1. P Ge.20) Abnormal T4 (%) 0 (0) 0 (0) 0 (0) 0 (0) 3.4% (35) T4 median (ng/dL) 1.2 (0. Z Zhang. The most critical period for brain development is from the second trimester of pregnancy to the third year after birth.9% (2) Table7.0 μIU/mL. A positive correlation between the milk iodine concentrations of lactating women and the urinary iodine concentrations of their infants by scatter plot (no.1 (0.60) 1.1 (0.65-2.36-3. Relationship between urinary iodine and thyroid function of women Groups <150 μg/L >150 μg/L All N 114 110 224 TSH(μIU/mL) T4(ng/dL) Abnormal Abnormal Median Median (%) (%) 1.605 (<0.0 μIU/mL.98 100% (34) 1. among that 11% of TSH were > 4.3% (7) 19.4 -4. which indicated that women with lower urinary iodine concentrations may have a higher risk of developing thyroid function disorders than those with higher urinary iodine concentrations (Tables 7).41 (0.50) 1 (0.40) 1. The percentage of TSH outside the normal range in women with lower urinary iodine was higher than that in women with higher urinary iodine. Relationship between urinary iodine and thyroid function The women were divided into two groups (lower and higher urinary iodine groups) according to the urinary iodine cut-off of 150 μg/L. 14.84-1.96) 1. Only one woman had T4 concentrations above the reference range and one was below the reference range (Table 6).1 50%(1) 2.545 (0.57) 1.002->75) 1.36-3.3 (1. Y Wang and S Wang 37 900 brest milk iodine(μg/L) 800 700 600 500 400 300 200 100 0 0 100 200 300 400 500 600 700 UI of infants(μg/L) 800 900 Fig 2.Y Wang.60) 1 (0. To prevent iodine deficiency disorders.1 100%(2) iodine concentrations of lactating women and urinary iodine concentrations of their infants.3 ng/dL and that of TSH was 0.20) 1.82-1.002->75) Abnormal TSH (%) 0 (0) 14.8% (2) 0.1 50%(1) 1.775 (<0.95 64. the WHO/UNICEF/ICCIDD established that the median . TSH concentrations of 15.4% of all women were above or below the reference range.2% (10) 15.3% (12) 1. Figure 2 shows positive correlation between urinary iodine concentrations in infants and breast milk iodine concentrations of lactating women by scatter plot.9% (7) 22% (11) 14.00-1.7% (22) 1.01 35.53) 2.99 (0.15-6. 15 Normal levels of thyroid hormones are required for optimal development of the brain.3% in women with urinary iodine > 150 μg/L.70) 2.7% in women with regard to urinary iodine < 150 μg/L and 35. DISCUSSION Iodine deficiency is the most important preventable cause of mental retardation worldwide. Table 6. =57 sites).41-3. The percentage of TSH outside the normal range was 64.37-8. TSH and FT4 concentrations The reference range of T4 was 0.98 (<0.93-1.002-5.

Optimal iodine intake is necessary to fully realize the human intellectual capabilities in a community. 12. Crutchfield HE. Determination of iodine in urine mild and vigorous digestion methods followed by cericarsenite reaction. Hao Y. Ministry of Health. Francisco Escobar del Rey and Gabriella Morreale de Escobar. 1989:231. 3. Influence of iodine prophylaxis on thyroid function and iodine excretion in Sweden and Germany. 1995. 11. 13. 18. Sedor F. Wageningen. Stubbe P. 18. 2008BAC40B04 and 2007BAC03A10) and the Project of National Natural Science Foundation of China (40675077). were carried out in pregnant women from the USA and showed respectively. decreased T3 to T4 ratios. Chin J Endemiol. 2007. Hence. Maria Jesus Obregon. the central nervous system(CNS) deficits in children born to mothers with low circulating T4 during pregnancy. Trends Endocrinol. Geneva: WHO. Methods for measuring iodine in urine. 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Brain development of infants has a obvious relationship with their mother’s thyroid function and special attention will be paid to the role of thyroid hormone in the relationship between the mother and the fetus. This study found a significant decrease in milk iodine from women breastfeeding for more than six months. Acta Endocrinol. Supplementation with iodine during pregnancy results in increased FT4. Xu HK. China National IDD Surveillance in 1997. Iodine requirements in pregnancy and infancy. IDD Newsletter. Dunn AD. Assessment of the iodine deficiency disorders and monitoring their elimination. Chen JX. 7. the iodine status of breastfed infants is better than that of formula fed infants. the iodine concentration in human milk varies widely due to environmental.(Suppl 274): 47-8. China’s Ministry of Health. Li ZZ. Some study showed that relative hypothyroxinemia in the first trimester is a potential risk for neurodevelopment of child. Accessed January 18. People s Health Publishing House. 2000. 14. Netherlands. Hannemann G. lactating women and infants are within the range of optimal iodine status. Iodine supplementation during pregnancy: a public health challenge.4% women’s TSH were abnormal. World Health Organization/International Council for the Control of the Iodine Deficiency Disorders/United Nations Children Fund (WHO/ICCIDD/UNICEF). Gutekunst R.3-21 (in Chinese).23. AUTHOR DISCLOSURES All authors declare that they have no financial interest in and have received no funding for the work presented in this paper. Iodine in human milk: perspective for infant health.59:269-78. However. 19 may suffer from iodine deficiency. Pediatrics. 8. without adverse effects25. it is indicated that pregnant women. The thyroid and its diseases. In addition. Available at: <http://www. 2001. Nutr Rev.161 (in Chinese). Document No. which indicated that the infants’ iodine status is affected by the mother’s iodine status. Thal H. 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01)。婴儿尿碘与母亲乳汁碘 之间存在正相关性 (r = 0. Zhongliang Zhang MS3. lactating women and infants (0-1 yr) residing in areas with an effective Universal Salt Iodization program Yanling Wang PhD1. Lanzhou Gansu. China 3 The first people hospital of Lanzhou city. Lanzhou Gansu.526. China 食盐加碘措施有效落实地区孕妇、哺乳期妇女及婴儿碘 营养和甲状腺功能 本研究的目的是评价食盐加碘措施有效落实地区孕妇、哺乳期妇女及婴儿的碘营 养状况及甲状腺功能。在碘盐覆盖率从 2000 年一直高於 90%的地区随机选择不 同生理阶段的孕妇、哺乳期妇女及婴儿,采集其尿样进行尿碘检测,采集妇女的 血样进行 T4 和 TSH 测定,同时采集哺乳期妇女的乳汁测定乳碘。早、中及晚期 孕妇,哺乳不足半年及半年以上妇女及婴儿的尿碘中位数分别为 233 、 174 、 180、147、126 和 145 μg/L。乳汁碘中位数为 163 μg/L。哺乳早期妇女尿碘低於 150 μg/L 所占的比例小于哺乳晚期妇女 40% (p < 0.40 Iodine status and thyroid function of target people Original Article Iodine status and thyroid function of pregnant. Lanzhou University.4% 妇女的 TSH 异常,这些妇女尿碘值多数低于 150 μg/L。全民食盐加碘能满足大 多数重点人群碘营养需要,但仍有部分人存在碘缺乏。为保证每个新生命免受因 缺碘所造成的脑损伤,应对重点人群进行碘营养监测,并根据监测结果进行適度 补充碘。 关键词:碘营养、碘盐、甲状腺激素、尿碘、乳碘 .000)。有两个妇女的 T4 值异常。共计 15. Lanzhou Gansu. China Gansu center for diseases control and prevention.2. Lanzhou University. Lanzhou Gansu. China 4 College of Atmospheric Sciences. p = 0. Shigong Wang MS4 1 2 College of Earth and Environment Sciences. Pengfei Ge MS2. Yibo Wang SD1.